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wp <br /> APPLICATION FOR PERMIT 1 1r UU <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> . PERMIT EXPIRES 1 YEAR `ROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) <br /> ° Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealthSe ee. <br /> + Job Address ! City l" ) Lot Sita/Acreage <br /> Owner's Name � r j t�'T Address ° - �C t _ ._. Phone h µ <br /> Contractor I�J �14C.[ Address _ Cense No, 3oglq Phone r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE-TO-NEAREST:-SEPTIC-TA'NK SEWER-LINES" �-" """""^" DISPOSAL-Ft D PROPrL-INE-- �4---� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL f PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom © Manteca Dia. of Well Excavation Dia._of Well Casing <br /> U Domestic I Private ❑-Gravel_Pack.0-Tracy Type of Casing A .Specifications <br /> M Public (1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> f µ 0 Irrigation ._._,.Apwox. Depth ❑ Eastern Surfice Sedl installed by i <br /> I Repair Work Done 0 Type of Pump t'i H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth t <br /> Depth Filler Material i Depth t ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public-sewer is <br /> f available within 200 feet.) <br /> Installation will serve: ResidenceL­Gommercial /Other t ` <br /> Number of living units: Number of bad. o s r g € <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg LCapacity No.;Compartments - <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Welf ,Foundation — Property Line <br /> k <br /> LEACHING LINE CL-40. 8 Length of linesp _ Total lengthlsize <br /> FILTER BED [_i Distance to nearest: Well Foundation Property Line C <br /> k � <br /> SEEPAGE PITS I(J_.Bepth Sire --� --:-Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 4 DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and a <br /> rules'end regulations of the San Joaquin County I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation-Iowa of California," Contractor's hiring or sub-contracting signature <br /> ce 'les the following: "I certify that in the performance of the workfor which this permit is issued, I shall employ,persons subject to workman's compensa- <br /> tl n laws li}ornia <br /> T plicant 1.c II for a r uired i c 'on �edra`w6_go_n verse side) <br /> „Title:___ � 1ff . J,: -Date: <br /> DEPARTMENT USE ONLY (� 1 <br /> k A lication Accepted I Date —`1 L� C7 Area' <br /> } 'l <br /> Pit o Grout Inspection b �� Date r �u Final Inspection by f Date <br /> ditLonal Comments: <br /> Applicant - Return all copiee'tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION' PERVITTSE'RVICES µy <br /> x 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA -052011 <br /> FEE INFO AMOUNT Dt1E.� AMOUNT REMITTED CASH e7_ RECEIVED BY DATE PERMIT'N0. <br /> . <br /> FH - <br /> 13 <br /> 74 eNEV.l,xsl <br /> EM^, 114-,06 -., � ty -0 T3- - 0- 7� <br />